Benefits of Exercise for Patients with
Rheumatoid Arthritis
Laura C. Rall, PhD, RD* Ronenn Roubenoff, MD, MHS*†
䊏
*Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University;
†Tupper Research Institute, Department of Medicine,
New England Medical Center, Boston, Massachusetts
䊏 ABSTRACT
Rheumatoid arthritis (RA) is a chronic, systemic, autoim-
mune, inflammatory disorder of unknown etiology and
is the most common type of inflammatory arthritis. The
disease is most often characterized by morning stiff-
ness, joint pain, tenderness, and swelling. Other sys-
temic symptoms, such as anemia, increased free radi-
cal production, muscle atrophy, and weakness, also
occur. Most likely, a combination of these factors con-
tributes to physical inactivity as well, which, in turn, rein-
forces the muscle wasting. Despite these barriers, it is
now becoming recognized that patients with well-con-
trolled RA can tolerate increased physical activity un-
der carefully supervised conditions and that there are
many benefits to exercise. This article reviews the ef-
fects of various types of physical activity on RA, with
particular emphasis on studies that have examined the
use of strength training in clinical practice for the man-
agement of RA. Without exception, the studies have
shown that increased physical activity in patients with
RA improves physical capacity without exacerbating
disease activity. Important criteria to consider when
recommending an exercise program for patients with
RA are outlined. Nutr Clin Care. 2000;3:209–215 䊏
KEY WORDS: rheumatoid arthritis, exercise
Reprint requests to Ronenn Roubenoff, MD, Nutrition, Exercise Physiol-
ogy and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition
Research Center on Aging, 711 Washington Street, Boston, MA 02111.
E-mail: roubenoff@hnrc.tufts.edu
© 2000 Tufts University, 1096-6781/00/$15.00/0 Nutrition in Clinical Care,
Volume 3, Number 4, 2000 209–215
Rheumatoid arthritis (RA) is a chronic, systemic,
autoimmune, inflammatory disorder of unknown
etiology and is the most common type of inflamma-
tory arthritis, affecting approximately 1% of the
population.1 Women are affected 2–3 times more
often than men,2 with the peak incidence occur-
ing between the fourth and sixth decades of life.3
Rheumatoid arthritis is most often characterized by
morning stiffness, joint pain on motion, or tender-
ness and swelling, typically in a symmetric pat-
tern.4
The synovium is the crucial site in the onset of
joint deterioration.5 Synovial tissue from patients
with RA is characterized by a predominance of prolif-
erating T-lymphocytes (CD4⫹ more so than CD8⫹),
immunoglobulin production, and spontaneous cy-
tokine production.6 Other systemic symptoms,
such as anemia, increased free radical production,
muscle atrophy, and weakness, also occur. Most
likely, a combination of these factors contributes to
physical inactivity as well, which, in turn, reinforces
the muscle wasting. Decreased muscle strength (65–
75% of normal), endurance (45% of normal) and
aerobic capacity (80% of normal) were found among
patients with RA when compared to a healthy refer-
ence group matched for age and sex.7
Causes of reduced muscle strength and physical
activity are probably multifactorial and include a
combination of disuse, response to pain or myosi-
tis, physical contractures that make exercise tech-
210 䊏 RALL AND ROUBENOFF
nically difficult, medications, or a result of de-
creased demand during activities of daily living.8
Despite the barriers, it is now becoming recog-
nized that patients with well-controlled RA can tol-
erate increased physical activity under carefully su-
pervised conditions and that there are many benefits
to exercise. This article reviews the effects of vari-
ous types of physical activity on RA, with particular
emphasis on studies that have examined the use of
strength training in clinical practice for the man-
agement of RA.
EXERCISE INTERVENTIONS
It’s been more than 2 decades since it was first rec-
ognized that patients with RA had low physical per-
formance capacity. Early studies used varying types
of exercise to demonstrate improvements in physi-
cal performance capacity, cardio-respiratory fitness,
muscle strength, and activities of daily living in
patients with RA, without detrimental effects on
disease activity or joint damage.9–11 More recently,
numerous studies have examined the effects of
various types of exercise on RA (Table 1), and al-
though this summary of recent studies is by no
means exhaustive, the conclusions are consistent
with and support the findings of earlier studies.
Without exception, these studies have shown that
increased physical activity in patients with RA im-
proves physical capacity without exacerbating dis-
ease activity.
Clinical Trials
Studies from our own laboratory utilizing high-
intensity progressive resistance strength training
were among the first to apply similar training stan-
dards to patients with RA as those applied to
young, healthy individuals.12–14 Progressive resis-
tance training is a form of exercise training that em-
ploys weight lifting at steadily higher weights to in-
crease muscle mass and strength, but has little
effect on aerobic fitness. We studied 8 subjects
with RA, 8 healthy, young subjects, and 8 healthy,
elderly individuals, all of whom underwent 12 weeks
of twice-weekly, progressive resistance strength
training at 80% of their 1-repetition maximum (the
most weight that can be lifted in good form). Six
healthy, elderly, nontraining control subjects were
also studied.
Nutr Clin Care, July/Aug 2000–Vol 3, No. 4
After 3 months of training, all exercise groups
demonstrated improvements in strength compared to
control subjects (RA group ⫽ 57%, young ⫽ 44%,
elderly exercise ⫽ 36%, controls ⫽ 9%). Subjects
with RA exhibited no change in the number of
painful or swollen joints. They had significant re-
ductions in self-reported scores for pain (21%) and
fatigue (38%), improved 50-foot walking times, and
improved scores on tests of balance and gait. Fur-
thermore, increased protein catabolism, observed
at baseline in patients with RA, was no longer evi-
dent after strength training. These benefits occurred
without any adverse effects on immune function or
changes in body composition among any of the
subject groups.
The majority of clinical studies carried out more
recently have also involved a strength training inter-
vention; other studies have utilized aerobic exercise
or hydrotherapy (water exercises and aerobics, in-
cluding working with paddles to increase resistance
in the water, walking in chest-deep water, or swim-
ming).15–17 Water-based exercises are ideal for pa-
tients with severe RA because the muscles can be
trained with minimal stress to the joints.
In most studies, the exercise intervention was
carried out for 2 to 3 months, although a recent
study by Hakkinen et al18 involved training sub-
jects over a 12-month period and is the longest
study to date of strength training in subjects with
RA. In this study, 32 subjects with early RA carried
out strength training 2 times a week at home with
moderate loads of 50% to 70% of their 1-repetition
maximum. Thirty-three control subjects, also with
early RA, performed only recreational physical
activities and range-of-motion exercises. After 12
months of training, subjects in both groups had im-
proved strength (22%–35% among training subjects
and 3%–24% among controls), but training subjects
had significantly greater strength than control sub-
jects. Scores on disease activity variables, as well as
functional capacity, were significantly improved in
both groups of subjects. However, a comparison of
training vs. control subjects at the end of the 12-
month period revealed significant differences be-
tween the 2 groups (in favor of the training group)
in terms of erythrocyte sedimentation rate and
Modified Disease Activity Score. Bone mineral den-
sity was also measured, showing minor changes
over the 12-month period for both groups. A mini-
mally supervised strength training regimen resulted
Table 1. Summary of Evidence: Exercise and Rheumatoid Arthritis (RA)
Reference Subjects Exercise Intervention Primary Outcomes* Conclusions

Rall et al.13 Training: n ⫽ 8 RA, 12 weeks (twice weekly) ↑ strength; no change in High-intensity strength
8 healthy young, high intensity (80% 1-RM†) painful/swollen joints in RA training is feasible and
8 healthy elderly; progressive resistance subjects; ↓ self-reported safe in patients with
Non-training: n ⫽ 6 training pain/fatigue; improved well-controlled RA;
healthy elderly balance/gait and walking times improves strength, pain,
controls and fatigue no
exacerbation of disease
activity
Rall et al.12 Training: n ⫽ 8 RA, 12 weeks (twice weekly) No change in peripheral High-intensity resistance
8 healthy young, high intensity (80% 1-RM†) blood mononuclear cell training does not adversely
8 healthy elderly; progressive resistance subsets, interleukin (IL)-1 ␤, affect immune function in
Non-training: n ⫽ 6 training tumor necrosis factor-␣, subjects with RA
healthy elderly IL-6, IL-2, or prostaglandin
controls E2 production, lymphocyte
proliferation, or delayed
type hypersensitivity skin
Nutr Clin Care, July/Aug 2000–Vol 3, No. 4

Rall et al.14 Training: n ⫽ 8 RA, 12 weeks (twice weekly)
8 healthy young, high intensity (80% 1-RM†)
8 healthy elderly; progressive resistance
Non-training: n ⫽ 6 training
healthy elderly
controls
Hall et al.15 n ⫽ 139 RA, 4 weeks, 30 minute
randomly assigned sessions twice weekly;
to 1 of 4 groups group 1, hydrotherapy;
group 2, seated
immersion; group 3,
land exercise; group 4,
progressive relaxation
van den Ende20 n ⫽ 100 RA 12 weeks; group 1,
(well-controlled full weight bearing &
disease) randomly stationary bike at 70%– 85%
assigned to 1 of 4 maximum heart rate;
exercise groups group 2, ROM &
(p ⫽ 25) isometric exercises;
group 3, individual ROM &
isometric exercises;
response
↑ protein breakdown rates
in RA subjects were
diminished after strength
training
Arthritis Impact
Measurement Scales →
↓ pain; ↑ motional status
for all groups.
Hydrotherapy group
only had additional
improvement in joint
tenderness
and knee ROM‡
↑ aerobic capacity,
muscle strength,
joint mobility in
high-intensity group;
no change in disease
activity; discontinuing
training led to loss of
benefits within 12 weeks
Strength training has
beneficial effects in terms
of body composition,
reducing protein
catabolism in patients
with RA
Although all patients
experienced some
benefit, hydrotherapy
produced the greatest
improvements
Intensive dynamic training
is more effective in
improving aerobic
capacity, joint mobility,
and muscle strength than
ROM or isometric training
Exercise in Rheumatoid Arthritis

group 4, home instructions

for isometric & ROM
䊏

exercises

Continued
211
 䊏212

Table 1. (Continued)
Reference Subjects Exercise Intervention Primary Outcomes* Conclusions
19
Hakkinen et al. n ⫽ 39 RA (21 6 months progressive ↑ strength in training vs Need for continuous
strength training, 18 strength training control subjects; period physical exercise with
control);18 healthy (40%– 80% 1-RM), of detraining led to loss sufficient intensity to
controls twice weekly during of increase for all measures minimize or prevent loss
first 4 months, 2–3 sessions but grip strength of muscle strength and
during last 2 months, functional capacity
using elastic rubber
bands
RALL AND ROUBENOFF

Komatireddy et al.24
Neuberger et al.16
Noreau et al.17
Bell et al.21
Hakkinen et al.18
n ⫽ 25 RA training 12 weeks (ⱖ 3 times per In training vs control Low-load resistive muscle
patients, 24 RA week) home-based subjects, improved joint training increased
controls training program (circuit count, sit-to-stand time, self-reported functional
weight bearing using confidence in ability to capacity, and is clinically
light loads with high exercise, less nighttime pain safe for functional class II
repetitions) and III patients with RA
n ⫽ 25 RA (no 12 weeks low-impact ↑ aerobic fitness and grip Patients with RA may
control group) aerobic exercise strength; ↓ pain and walk decrease fatigue and gain
time; no change in joint other benefits without
count, sedimentation rate worsening disease
n ⫽ 10 women, 8 weeks, twice weekly ↓ depression, anxiety, Modified dance-based
functional class III aerobic dance-based fatigue, tension exercise program is
RA (no control exercise program feasible and results in no
group) deleterious effect on
health status
n ⫽ 76 RA patients 4 visits or 3 hours of physical Improvement in Stanford Community-based PT
undergoing PT, 74 therapy (PT) over 6 weeks Arthritis Self-Efficacy Scale, improved self-efficacy,
RA controls, RA Knowledge Questionnaire, disease management
moderate to severe morning stiffness knowledge, and morning
disease stiffness in people with RA
Training: n ⫽ 32 12 months (twice weekly) ↑ strength in training vs Minimally supervised
RA; Control: n ⫽ of dynamic strength control subjects strength training led to
33 RA training with moderate increased strength without
loads of 50%–70% of 1-RM. detrimental effects on
disease activity

*P ⬍ .05.
†
1-RM ⫽ 1-repetition maximum: the maximum weight that can be lifted once using acceptable form, without help of the whole body or muscle groups other than the specific group involved in
performing the exercise.
‡
ROM ⫽ range of motion.
Nutr Clin Care, July/Aug 2000–Vol 3, No. 4
Nutr Clin Care, July/Aug 2000–Vol 3, No. 4 Exercise in Rheumatoid Arthritis 䊏 213

in significant improvements in muscle strength with-

out detrimental effects on disease activity. Thus, this
study and others have confirmed our earlier finding
that an exercise intervention is feasible and safe for
patients with RA.
Of note, a previous study by these same authors19
clearly demonstrated that strength-training-induced
increases in muscle performance in patients with
early stages of RA were lost to a great extent during
a lengthy (3-year) detraining period. Other research-
ers have found that the gain in physical capacity af-
ter completing an exercise program is decreased in
as little as 3 months if therapy is not continued.20
Therefore, patients should continue some strength
training after the intensive training period has been
completed in order to retain the increased strength
level achieved. Even once-weekly training may
help maintain such gains.
Other identified benefits of exercise include re-
ductions in morning stiffness, depression, and anxi-
ety,15,17 and increased disease-management knowl-
edge.21 The ultimate benefit is that patients with
RA experience improved functional capacity after
undergoing an exercise intervention, regardless of
the type of physical activity involved. The effect of
exercise on the determinants of functional status in Figure 1. Relationship of rheumatoid arthritis to nutritional ab-
patients with RA is illustrated in Figure 1. normalities that lead to disability.

who have arthritis and the lack of insurance reim-

RECOMMENDATIONS FOR
DISEASE MANAGEMENT
The finding that patients with RA can safely engage
in vigorous physical activity represents a major
change in the way these patients can be treated. As
recently as a decade ago, high-intensity resistance
training was avoided in patients with RA due to con-
cern about exacerbating joint inflammation or rup-
turing tendons, popliteal cysts, or joint capsules.8
However, with recent evidence that patients with
RA can safely perform high-intensity strength train-
ing at the same level as healthy control subjects and,
furthermore, can obtain great benefit from increased
physical activity, it is now recognized that the tradi-
tional prescription for inflamed joints—local and sys-
temic rest—only serves to increase adverse effects.22
Exercise therapy is now viewed as one of the cor-
nerstones of the management of RA.22
Major problems today are the limited availability
of trainers experienced in working with patients
bursement for such training. Most physical thera-
pists are not familiar with high-intensity resistance
training, and, in general, physical therapy is de-
signed to treat damaged joints with low-intensity,
high-repetition programs that are the opposite of
the training needed to increase muscle mass.
It is important to point out that all the above
mentioned studies have included patients with
well-controlled or early RA. There has been general
agreement that strength training is not appropriate
for patients during an acute flare of RA, and that
the best type of exercise therapy for these patients
is stretching, nonweight-bearing isometric exer-
cises, or hydrotherapy.22 It is crucial to emphasize
safety components of an exercise program for pa-
tients with RA.19 One must consider the phase of
the disease and establish appropriate evaluation
methods for the training period. The patient should
be taught to differentiate muscle soreness from
joint pain and to adapt the training program (ie, by
214 䊏 RALL AND ROUBENOFF Nutr Clin Care, July/Aug 2000–Vol 3, No. 4

Table 2. Excercise Program Recommendations for Patients with Rheumatoid Arthritis

Clinical Approach Comments

Pre-excercise considerations
Rheumatoid arthritis disease status
Presence of contraindications
Strength training should be prescribed only for patients with well-
controlled RA. Hydrotherapy is useful in those with more active disease
General: recent MI, uncontrolled hypertension, aortic aneurysm,
severe valvular heart disease

Arthritis-specific: large effusions, ligamentous laxity, popliteal cysts

Training regimens
Excercise types Progressive resistance training (“conditioning”) to reverse
weakness and cachexia. Add aerobic component to reduce fat
mass, improve cardiopulmonary status. Can be done in pool to
avoid stressing joints; bicycling, walking OK
Frequency 2-3 ⫻/week: this frequency maintains positive effects;
can mix and match strengthening and aerobics
Duration Ongoing: ongoing program necessary to maintain positive effects
Intensity Variable: depending on disease severity

Strengthening: goal is 80% of 1-repetition maximum

Aerobic: 70% of predicted maximum heart rate (220 ⫺ age)

Essential follow-up
Body weight Weight loss may indicate inadequate dietary intake or may be an
additional goal of therapy
Diet As appropriate depending on goals
1-repetition maximum Monitoring insures constant level of high-intensity excercise is
maintained as strength increases

decreasing resistance, or resting a particular joint)
to changes in disease activity.
Important criteria to consider when recom-
mending an exercise program for patients with RA
are outlined in Table 2.
progression of RA as data on this topic is limited.23
Future studies should also focus on continuing to
obtain data on the benefits of exercise in terms of
functional outcomes, because improving functional
capacity is the ultimate goal of any therapy program.

This material is based on work supported by the

SUMMARY AND CONCLUSIONS
The consensus in the recent literature is that an ex-
ercise intervention is feasible and safe among pa-
tients with well-controlled RA and that exercise has
many benefits, including improved strength, mobil-
ity, self-efficacy, disease-management knowledge,
and reduced pain and fatigue. Furthermore, no
study identified any adverse effects of an exercise
intervention on disease activity. Van den Ende has
confirmed these findings in a recent systematic re-
view of the literature.23 It also has been determined
that patients with RA need to continue exercising
after the intensive intervention period in order to
maintain any benefit in terms of strength.25
Further research is needed to investigate the
long-term effect of strength training on radiological
US Department of Agriculture, under Cooperative
Agreement no. 58–1950–001. Any opinions, find-
ings, conclusions, or recommendations expressed in
this publication are those of the authors and do not
necessarily reflect the view of the US Department of
Agriculture.
Laura C. Rall, PhD, RD, and Ronenn Roubenoff,
MD, MHS, have indicated no significant relation-
ships with commercial supporters.
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